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Residents' time limit does not hurt patients, confirms new study

According to a study published online today in the newspaper, the reduction in residential training hours does not significantly affect the quality of care provided to patients, including inpatient mortality. BMJ.

With data showing similar results for patients, one expert said that it was now necessary to move from the debate about the total number of hours spent by hospital residents to how these hours were spent.

In 2003, the Council for Accreditation of Higher Medical Education (ACGME) imposed on residents a number of weeks of work not exceeding 80 hours and a duration of work not exceeding 30 hours. The changes were put in place as a result of a widely announced death in a New York University Hospital and growing concerns about the safety of patients being cared for by tired residents. Subsequent reforms in 2011 limited the duration of shifts to 16 hours for trainees and 28 hours for trainees. However, in 2017, ACGME allowed trainees from some programs to work longer and also made other changes.

"The reduction in resident work hours has sparked a debate over whether working less time in residency would lead to the insufficient insertion of physicians practicing in independent practice," said Lt.-Mar. author, Anupam B. Jena, MD, Ph.D., Harvard Medical School, Boston, Massachusetts. Medscape Medical News by email.

To answer the question, Jena and colleagues compared patient outcomes for physicians trained in internal medicine before and after residential work hours reforms. They found that the reduction in hours of work was not related to hospital mortality, readmissions and the cost of care.

"These results should certainly inform the debate, but do not risk ending it," said Jena.

"It's important to recognize that hospital care differs from what it was 20 or 30 years ago, so reducing the role of a single physician in determining patient outcomes." It is possible that the trainee of the future is adequately prepared for practical independence with less than 80 hours per week during the residency, "he explained.

When asked to comment, Sanjay Desai, MD, vice president of education and director of the internal medicine program at Johns Hopkins University in Baltimore, Maryland, said the study was important as it evaluated the practicing doctors after completing their training. Earlier studies, on the other hand, assessed physicians during their training.

For example, the results of the individualized comparative efficacy of models optimizing patient safety and resident training (iCOMPARE) have shown that with limited hours, patient outcomes and trainees' academic outcomes do not occur. Were not altered.

However, few studies have evaluated the long-term effects of a reduction in the number of training hours. Desai, who has served on the ACGME committee that sets the limits of the number of hours of residency and whose research is concentrated in this area, explained that only one other study conducted in Florida had successful. The results may not be generalized to other states.

The study by Jena and colleagues "is a unique contribution because it really evaluates the performance of clinicians at the end of their training, and she says that the discussion about the number of hours spent in the hospital during training is no longer an important discussion, "says Desai.

Instead of talking about the absolute number of hours spent at work, the focus should be on how these hours are spent, he explained.

Physician burnout is one of the most important variables to evaluate. Other important variables include professionalization, physician attitudes, communication skills, development of specific clinical skills, and the impact of work hours on physician health.

"This study confirms, in my opinion, that we need to go from the number of hours to differences in the way we spend these hours and associate these factors with other outcomes, including well-being This type of research is essential for the country, "he said.

Nearly 500,000 analyzed entries

In this study, Jena and colleagues analyzed 485,685 admissions for Medicare Part B patients between January 2000 and December 2012.

They compared the results among patients in the care of physicians who were in first-year independent practice and who had completed residency before (2000-2006) and after (2007-2012) ACGME reforms with patient outcomes supported by senior internists in training. 10 years of independent practice in the same years. An analysis of the differences in the differences showed no significant difference between the training periods for any of the results examined.

Among first-year internists, the 30-day mortality rate was 10.6% for those who completed their training before the reforms and 9.6% for those who completed their training after the reforms. Among older physicians, the rates were 11.2% and 10.6% for the same periods.

Similarly, 30-day readmission rates among patients treated by first-year internists after reform and after reform were the same at 20.4%. For experienced internists, the rates were 20.1% and 20.5% in the same years.

Hospitalization expenses were also similar. Among the first-year internists, expenditures were $ 1,116 and $ 1,267 per hospitalization for those in the pre- and post-reform groups, respectively. Hospitalization expenses for senior internists were $ 1331 and $ 1,599 for the same periods.

The study presents several potential limitations, including its observation plan and the inclusion of only internists. The authors point out that the results may not be generalized to other types of residents, especially surgical residents, for whom exposure to a certain volume of procedures may make a difference.

In addition, the use of the 30-day mortality assessment criterion may have masked the differences between the study groups. However, decision makers are probably the most interested in this parameter and will change the rules on hours of work if differences are found, said Desai.

The study was sponsored by the National Institutes of Health. One or more authors received consulting fees from one or more of Pfizer, Hill Rom Services, Bristol-Myers Squibb, Novartis, Amgen, Eli Lilly, Vertex Pharmaceuticals, AstraZeneca, Celgene, Tesaro, Sanofi Aventis, Biogen, Precision Health Economics, Analysis Group and Precision Health Economics. An author is an employee of Devoted Health. Desai did not reveal any relevant financial relationship.

BMJ. Posted online July 10, 2019. Full text

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